Pain and Social Security Disability

Social Security disability claimants frequently suffer from subjective complaints of pain that make it difficult, and in some cases impossible, to perform substantial gainful activity on a sustained basis. Applicable statutory and regulatory law provides guidance regarding the analysis of a claimant’s subjective complaints of pain. The Social Security Administration has also issued rulings discussing the analysis of complaints of pain. The purpose of this topic is to provide an overview of applicable laws, regulations, and rulings, and circuit court case law governing this critical area of law.

Statutes

42 U.S.C. § 423(d)(5)(A)

42 U.S.C. § 423(d)(5)(A) dictates that in determining whether an individual suffers from a disability:

an individual’s statements as to pain or other symptoms shall not alone be conclusive evidence of disability . . . there must be medical signs and findings, established by medically acceptable clinical or laboratory diagnostic techniques which show the existence of a medical impairment . . . which could reasonably be expected to produce the pain or other symptoms alleged and which, when considered with all evidence required to be furnished under this paragraph (including statements of the individual or his physician as to the intensity and persistence of such pain or other symptoms which may reasonably be accepted as consistent with the medical signs and findings), would lead to a conclusion that the individual is under a disability.

Regulations

20 C.F.R. §§ 404.1529, 416. 929

The foregoing regulations set forth a detailed two part analysis for evaluating complaints of pain. The regulations first provide that statements about a claimant’s pain or other symptoms will not alone establish that a disability exists. There must be medical signs and laboratory findings which show that the claimant has a medical impairment(s) which could reasonably be expected to produce the pain or other symptoms alleged, and which, when considered with all of the other evidence (including statements about the intensity and persistence of pain or other symptoms which may reasonably be accepted as consistent with the medical signs and laboratory findings), would lead to a conclusion of disability.

If the medical signs or laboratory findings show that a claimant has a medically determinable impairment(s) that could reasonably be expected to produce the alleged symptoms, such as pain, the SSA then evaluates the intensity and persistence of the symptoms. In evaluating the intensity and persistence of symptoms, the SSA must consider all of the available evidence, including medical history, the medical signs and laboratory findings, and statements from treating or examining physicians or psychologists, or other persons about how the symptoms affect the claimant.

The SSA must always attempt to obtain objective medical evidence and, when it is obtained, consider it in reaching a conclusion as to whether a claimant is disabled. The SSA will not reject a claimant’s statements about the intensity and persistence of pain or other symptoms or about the effect the symptoms have on the ability to work solely because the available objective medical evidence does not substantiate the allegations.

Factors relevant to a claimant’s symptoms, such as pain, which must be considered include:

A claimant’s daily activities;

The location, duration, frequency, and intensity of pain or other symptoms;

Precipitating and aggravating factors;

The type, dosage, effectiveness, and side effects of any medication taken to alleviate the pain or other symptoms;

Treatment, other than medication, received for relief of the pain or other symptoms;

Any measures used to relieve pain or other symptoms; and

Other factors concerning functional limitations and restrictions due to pain or other symptoms.

Rulings

Social Security Ruling 96-3p

As explained by Social Security Ruling 96-3p, symptoms, such as pain, will not be found to affect an individual’s ability to do basic work activities unless the individual first establishes by objective medical evidence (i.e., signs and laboratory findings) that he or she has a medically determinable physical or mental impairment(s) and that the impairment(s) could reasonably be expected to produce the alleged symptom(s). The finding that an individual’s impairment(s) could reasonably be expected to produce the alleged symptom(s) does not involve a determination as to the intensity, persistence, or functionally limiting effects of the symptom(s). However, once the requisite relationship between the medically determinable impairment(s) and the alleged symptom(s) is established, the intensity, persistence, and limiting effects of the symptom(s) must be considered along with the objective medical and other evidence in determining whether the impairment or combination of impairments is severe.

Social Security Ruling 96-7p

Social Security Ruling 96-7p provides that when the existence of a medically determinable physical or mental impairment(s) that could reasonably be expected to produce the symptoms has been established, the intensity, persistence, and functionally limiting effects of the symptoms must be evaluated to determine the extent to which the symptoms affect the individual’s ability to do basic work activities. The adjudicator must then make a finding about the credibility of the individual’s statements about the symptom(s) and its functional effects.

Because symptoms, such as pain, sometimes suggest a greater severity of impairment than can be shown by objective medical evidence alone, the adjudicator must carefully consider the individual’s credibility if a disability determination or decision that is fully favorable to the individual cannot be made solely on the basis of objective medical evidence.

Social Security Ruling 95-5p

Social Security Ruling 95-5p (“SSR 95-5p”) provides that since symptoms sometimes suggest “a greater severity of impairment than can be shown by objective medical evidence alone, careful consideration must be given to any available information about symptoms.” This Ruling further requires that the ALJ “describe the relationship between the medically determinable impairment(s) and the conclusions regarding functioning which have been derived from the evidence, and . . . include a discussion of why reported daily activity limitations or restrictions are or are not reasonably consistent with the medical and other evidence.” Id.In addition, SSR 95-5p cautions that an adjudicator is not free to accept or reject a claimant’s complaints solely on the basis of personal observations.

Rather, in all cases in which pain or other symptoms are alleged, the determination or decision rationale must contain a thorough discussion and analysis of the objective medical and the other evidence, including the individual’s complaints of pain or other symptoms and the adjudicator’s personal observations. The rationale must include a resolution of any inconsistencies in the evidence as a whole and set forth a logical explanation of the individual’s ability to work . . . .

Complaints of pain need not be precisely corroborated by objective findings, but they must be consistent with medical findings. Dupuis v. Secretary of Health and Human Servs., 869 F.2d 622, 623 (1st Cir. 1989).

Second Circuit

In Mimms v. Heckler, the Second Circuit reiterated that it has long held that the subjective element of pain is an important factor to be considered in determining disability. Mimms v. Heckler, 750 F.2d 180, 185-186 (2d Cir. 1984). While an ALJ has the discretion to evaluate the credibility of a claimant and to arrive at an independent judgment regarding that pain, he or she must do so in light of medical findings and other evidence, regarding the true extent of the pain alleged by the claimant. Id., citingMcLaughlin v. Secretary of Health, Educ. and Welfare, 612 F.2d 701, 705 (2d Cir. 1980). An ALJ is not free to assume that a factor, such as pain, was considered in formulating a medical opinion when there is no evidence that such was the case. Id.

Due to the lack of clear recent circuit authority, see also Melchior v. Apfel, 15 F. Supp.2d 215, 219 (N.D.N.Y. 1998) for a description of the Second Circuit pain standard. As stated by the Melchior court, “it is well settled that a claimant’s subjective evidence of pain is entitled to great weight where it is supported by objective medical evidence.” Id., citingSimmons v. United States R.R. Retirement Bd., 982 F.2d 49, 56 (2d Cir. 1992) (quoting Rivera v. Schweiker, 717 F.2d 719, 725 (2d Cir. 1983) (citations omitted). An ALJ rejecting subjective testimony concerning pain and other symptoms “must do so explicitly and with sufficient specificity to enable the Court to decide whether there are legitimate reasons for the ALJ’s disbelief and whether his determination is supported by substantial evidence.” Id., citing Brandon v. Bowen, 666 F. Supp. 604 (S.D.N.Y.1987) and Valente v. Secretary of HHS, 733 F.2d 1037 (2d Cir. 1984).

Third Circuit

“Once an ALJ concludes that a medical impairment that could reasonably cause the alleged symptoms exists, he or she must evaluate the intensity and persistence of the pain or symptom, and the extent to which it affects the individual’s ability to work. This obviously requires the ALJ to determine the extent to which a claimant is accurately stating the degree of pain or the extent to which he or she is disabled by it.” Hartranft v. Apfel, 181 F.3d 358, 362 (3d Cir. 1999).

The Third Circuit has held that an ALJ must give serious consideration to a claimant’s subjective complaints of pain, even where the complaints are not supported by objective evidence. Mason v. Shalala, 994 F.2d 1058, 1067 (3d Cir. 1993). While there must be objective evidence of some condition that could reasonably produce pain, there need not be objective evidence of the pain itself. Id. Where medical evidence does support a claimant’s complaints of pain, the complaints should then be given ‘great weight’ and may not be disregarded unless there exists contrary medical evidence. Id.

In order for an ALJ to reject a claim of disabling pain, he must consider the subjective pain and specify his reasons for rejecting these claims and support his conclusion with medical evidence in the record. Matullo v. Bowen, 926 F.2d 240, 245 (3d Cir. 1990).

Fourth Circuit

In order for pain to be found disabling, the claimant must show a medically determinable impairment which could reasonably be expected to cause the pain which the claimant alleges he or she suffers. Craig v. Chater, 76 F.3d 585, 594 (4th Cir. 1996), citing 20 C.F.R. §§ 416.929 and 404.1529. After the claimant has met this threshold obligation, the intensity and persistence of the pain and the extent to which it affects her ability to work is evaluated. Id.at 595. While complaints of pain may not be rejected solely because objective evidence does not substantiate the claimant’s statements as to the severity and persistence of pain, a claimant’s statements need not be accepted to the extent they are inconsistent with the available evidence. Id.

Fifth Circuit

In order for pain to be found disabling, it must be “constant, unremitting, and wholly unresponsive to therapeutic treatment,” and pain complaints must also be supported by objective medical evidence. Chambliss v. Massanari, 269 F.3d 520, 522 (5th Cir. 2001). Based upon the medical evidence of record in Chambliss, the court found that substantial evidence supported the ALJ’s determination that the claimant’s alleged pain was not severe enough to preclude substantial gainful employment. Id.

The Fifth Circuit has held that to prove disability resulting from pain, an individual must establish a medically determinable impairment that is capable of producing disabling pain. Ripley v. Chater, 67 F.3d 552, 556 (5th Cir. 1995). Once a medical impairment is established, the subjective complaints of pain must be considered along with the medical evidence in determining the individual’s work capacity. Id. An ALJ cannot ignore altogether a claimant’s subjective complaints of pain. Bowling v. Shalala, 36 F.3d 431, 438 (5th Cir. 1994). Where the uncontroverted medical evidence shows a basis for the claimant’s complaints, the ALJ must articulate reasons for rejecting the claimant’s subjective complaints of pain. Falco v. Shalala, 27 F.3d 160, 163 (5th Cir. 1994).

Sixth Circuit

The Sixth Circuit has developed the following two-pronged test to evaluate a claimant’s allegations of disabling pain:

First, we examine whether there is objective medical evidence of an underlying medical condition.If there is, we then examine: (1) whether objective medical evidence confirms the severity of the alleged pain arising from the condition; or (2) whether the objectively established medical condition is of such a severity that it can reasonably be expected to produce the alleged disabling pain.

Pain alone may be sufficient to support a claim of disability. King v. Heckler, 742 F.2d 968, 974 (6th Cir. 1984). In evaluating subjective complaints of disabling pain, the Sixth Circuit evaluates whether there is objective medical evidence of an underlying medical condition, and if so, then (1) whether objective medical evidence confirms the severity of the alleged pain arising from the condition; or (2) whether the objectively established medical condition is of such a severity that it can reasonably be expected to produce the alleged disabling pain. Stanley v. Secretary of Health & Human Servs., 39 F.3d 115, 117 (6th Cir. 1994).

Seventh Circuit

The Seventh Circuit recently noted that:

[a]pplicants for social security benefits who claim to be disabled from working because of extreme pain make the job of a social security administrative law judge a difficult one. Medical science confirms that pain can be severe and disabling even in the absence of “objective” medical findings, that is, test results that demonstrate a physical condition that normally causes pain of the severity claimed by the applicant. E.g., Dennis C. Turk & Akiko Okifuji, Assessment of Patients’ Reporting of Pain: An Integrated Perspective, 353 Lancet 1784 (1999); Paula M. Trief et al., Functional vs. Organic Pain: A Meaningful Distinction? 43 J. Clinical Psych. 219 (1987).

Carradine v. Barnhart 360 F.3d 751, 753 (7th Cir. 2004). Thus, “‘once the claimant produces medical evidence of an underlying impairment, the Commissioner may not discredit the claimant’s testimony as to subjective symptoms merely because they are unsupported by objective evidence.’” Id., quoting Lester v. Chater, 81 F.3d 821, 834 (9th Cir.1996). Further, “‘[a] claimant’s subjective testimony supported by medical evidence that satisfies the pain standard is itself sufficient to support a finding of disability. Indeed, in certain situations, pain alone can be disabling, even when its existence is unsupported by objective evidence.’” Id., quoting Foote v. Chater, 67 F.3d 1553, 1561 (11th Cir. 1995) (per curiam) (citations omitted). “‘Pain, fatigue, and other subjective, nonverifiable complaints are in some cases the only symptoms of a serious medical condition. To insist in such a case, as the social security disability law does not . . . that the subjective complaint, even if believed by the trier of fact, is insufficient to warrant an award of benefits would place a whole class of disabled people outside the protection of that law.’” Id., quoting Cooper v. Casey, 97 F.3d 914, 917 (7th Cir. 1996) (citations omitted).

In Zurawski, the ALJ found that the claimant’s complaints of disabling pain were “not entirely credible due to the inconsistencies with the objective medical evidence, and inconsistencies with daily activities.” Zurawski v. Halter, 245 F.3d 881, 887 (7th Cir. 2001). However, the ALJ provided no further explanation regarding these “inconsistencies” and “should have explained the ‘inconsistencies’ between the claimant’s activities of daily living (that were punctured with rest), his complaints of pain, and the medical evidence.” Id.Since the court was unable to tell whether the ALJ “examined the full range of medical evidence as it relates to his claim,” it held that it lacked a sufficient basis to sustain the ALJ’s credibility determination. Id.at 888. An ALJ “must investigate all avenues presented that relate to pain, including claimant’s prior work record, information and observations by treating physicians, examining physicians, and third parties.” Luna v. Shalala, 22 F.3d 687, 691 (7th Cir. 1994).

As set forth in Pope v. Shalala, 998 F.2d 473, 482 (7th Cir. 1993), for pain or other symptoms to contribute to a finding of disability:

[a]n individual must first establish, by medical signs and laboratory findings, the presence of a medically determinable physical or mental impairment which could reasonably be expected to produce the pain or other symptoms alleged; and once such an impairment is established, allegations about the intensity and persistence of pain or the other symptoms must be considered in addition to the medical signs and laboratory findings in evaluating the impairment and the extent to which it may affect the individual’s capacity for work.

Eighth Circuit

An ALJ may discount a claimant’s allegations if there is evidence that a claimant was a malingerer or was exaggerating symptoms for financial gain. O’Donnell v. Barnhart, 318 F.3d 811, 818 (8th Cir. 2003). Several doctors suggested that O’Donnell might have been magnifying her pain due to a psychogenic overlay. However, even if true, that would not be a reason to discredit her allegations. An “‘ALJ cannot simply ignore . . . medical evidence that [claimant] suffers from pain having its origin in a psychological disorder.’” Id., quoting Mellon v. Heckler, 739 F.2d 1382, 1383 (8th Cir. 1984) (quoting Reinhart v. Secretary, 733 F.2d 571, 572-73 (8th Cir. 1984)). In any event, the doctors who examined and treated O’Donnell more recently did not indicate that she was magnifying her symptoms or malingering. Id.

Although the record credited by the ALJ may not contain sufficient objective medical evidence to support the claimant’s subjective complaints, the record as a whole does support them. Holmstrom v. Massanari, 270 F.3d 715, 722 (8th Cir. 2001). The record as a whole, including the claimant’s testimony and all of the medical records, corroborated Holmstrom’s subjective complaints in such a qualitative manner as to negate the inconsistencies pointed out by the ALJ. Id.

As stated by the Eighth Circuit, pain is a nonexertional impairment. Beckley v. Apfel, 152 F.3d 1056, 1059-60 (8th Cir. 1998). When assessing the credibility of a claimant’s subjective allegations of pain, the ALJ must consider the claimant’s prior work history; daily activities; duration, frequency and intensity of pain; dosage, effectiveness and side effects of medication; precipitating and aggravating factors; and functional restrictions. Id., citingPolaski v. Heckler, 739 F.2d 1320, 1322 (8th Cir. 1984). When rejecting a claimant’s complaints of pain, the ALJ must make an express credibility determination, detailing reasons for discrediting the testimony, set forth the inconsistencies, and must discuss the Polaski factors. Id.A claimant’s allegations of disabling pain may be discredited by evidence that the claimant has received minimum medical treatment and/or has taken only occasional pain medications. Id.

The issue is not whether the claimant suffers from any pain, but whether the claimant’s pain is so disabling as to prevent the performance of any type of work. McGinnis v. Chater, 74 F.3d 873, 874 (8th Cir. 1996). In Polaski v. Heckler, 739 F.2d 1320, 1322 (8th Cir. 1994), the Eighth Circuit set forth the following pain standard:

The adjudicator may not disregard a claimant’s subjective complaints solely because the objective medical evidence does not fully support them. The absence of an objective medical basis which supports the degree of severity of subjective complaints alleged is just one factor to be considered in evaluating the credibility of the testimony and complaints.

The ALJ may discount the claimant’s allegations of pain when he explicitly finds them inconsistent with daily activities, lack of treatment, demeanor, and objective medical evidence. Jones v. Chater, 86 F.3d 823, 826 (8th Cir. 1996) (noting the mere fact that working may cause pain or discomfort does not require a finding of disability).

Merely “quoting Polaski is not good enough, especially when an ALJ rejects a claimant’s subjective complaints of pain.” Hall v. Chater, 62 F.3d 220, 223 (8th Cir. 1995). In order to reject a claimant’s complaints, the ALJ must make express credibility findings and provide reasons for discrediting the testimony. Reynolds v. Chater, 82 F.3d 254, 258 (8th Cir. 1996), citingHall v. Chater, 62 F.3d 220, 223 (8th Cir. 1995). See alsoFlynn v. Chater, 107 F.3d 617, 621 (8th Cir. 1997) (noting that in applying the Polaski factors, it is “perfectly appropriate for an ALJ to find a claimant’s testimony to be credible, but disagree with the claimant’s ultimate conclusion of disability as derived from that testimony”).

Ninth Circuit

According to Cotton v. Bowen, 799 F.2d 1403 (9th Cir. 1991), the analysis of a claimant’s subjective complaints of pain consists of two prongs: (1) the claimant must produce objective medical evidence of an impairment or impairments; and (2) the claimant must show that the impairment or combination of impairments could reasonably be expected to (not that it did in fact) produce some degree of symptom. Smolen v. Chater, 80 F.3d 1273, 1282 (9th Cir. 1996) (finding that “the ALJ may not reject subjective symptom testimony under the Cotton analysis simply because there is no showing that the impairment can reasonably produce the degree of symptom alleged”).

Having determined that Ms. Thomas’ subjective complaints of pain were not credible, the ALJ had no need to explore whether Ms. Thomas’ pain was psychologically related, because pain is subjective and depends on the credibility of the claimant. Thomas v. Barnhart, 278 F.3d 947, 959 (9th Cir. 2002).

Once a claimant satisfies both parts of the first step, step two requires an analysis of the claimant’s credibility. Bergstad v. Commissioner of Social Security Admin., 967 F. Supp. 1195, 1205 (D. Or. 1997), citingSmolen v. Chater, 80 F.3d 1273, 1281 (9th Cir. 1996). In performing this assessment, the ALJ can reject the claimant’s testimony only for specific, clear and convincing reasons. Id. General findings by the ALJ are not sufficient: “rather, the ALJ must identify what testimony is not credible and what evidence undermines the claimant’s complaints.” Lester v. Chater, 81 F.3d 821, 834 (9th Cir. 1995). Pain testimony may not be discounted solely because it is not corroborated by medical findings. Chavez v. Department of Health & Human Servs., 103 F.3d 849, 853 (9th Cir. 1996).

If the claimant produces medical evidence of an underlying impairment, the Commissioner may not discredit the testimony of the claimant regarding subjective symptoms based solely on the fact that they are unsupported by objective evidence. Lester v. Chater, 81 F.3d 821, 834 (9th Cir. 1995).

The Tenth Circuit found that the ALJ’s credibility determination was “adequate,” stating:

Under Luna v. Bowen, the ALJ must decide whether a claimant’s subjective claims of pain are credible, considering such factors as ‘a claimant’s persistent attempts to find relief for his pain and his willingness to try any treatment prescribed, regular use of crutches or a cane, regular contact with a doctor . . . , the claimant’s daily activities, and the dosage, effectiveness, and side effects of medication.’ 834 F.2d at 165-66. Here, the ALJ found plaintiff’s complaints not completely credible based on the paucity of objective medical findings in the record, the fact that she had not been treated by her physicians during the nine months preceding the hearing, her failure to report arm numbness to her doctors, her lack of obvious discomfort at the hearing, and the fact that she was not taking prescription pain medication. As the ALJ relied on appropriate factors to support his decision, there was no error.

In one case, the plaintiff asserted an impairment that could reasonably have been expected to produce the disabling pain of which she complained. Because of this, the ALJ was required to determine whether he believed plaintiff’s assertion of severe pain, in light of all the relevant objective and subjective evidence. Winfrey v. Chater, 92 F.3d 1017, 1020 (10th Cir. 1996). Although this credibility determination is peculiarly within the province of the ALJ, it must be supported by substantial evidence. Kepler v. Chater, 68 F.3d 387, 391 (10th Cir. 1995).

In evaluating complaints of pain, the Tenth Circuit considers (1) whether the claimant proved by objective medical evidence an impairment causing pain; (2) whether there was a nexus between the impairment and the subjective complaints of pain; and (3) considering all of the evidence, whether the pain was disabling. Musgrave v. Sullivan, 966 F.2d 1371, 1376 (10th Cir. 1992); Luna v. Bowen, 834 F.2d 161, 164 (10th Cir. 1987). In considering step three, the ALJ must consider the following factors: the levels of medication and their effectiveness, the extensiveness of the attempts (medical or non-medical) to obtain relief, the frequency of medical contacts, the nature of daily activities, subjective measures of credibility that are peculiarly within the judgment of the ALJ, the motivation of an [sic] relationship between the claimant and other witnesses, and the consistency or compatibility of non-medical testimony with objective medical evidence. Huston v. Bowen, 838 F.2d 1125, 1132 (10th Cir. 1988). A finding of disability requires more than an inability to work without pain; rather, the pain must be so severe as to preclude any substantial gainful employment. Gossett v. Bowen, 862 F.2d 802, 807 (10th Cir. 1988).

Eleventh Circuit

The Eleventh Circuit has established a three-part “pain standard” that applies when a claimant attempts to establish disability through her own testimony of pain or other subjective symptoms. Id., See also Brown v. Sullivan, 921 F.2d 1233, 1236 (11th Cir. 1991). The pain standard requires:

Evidence of an underlying condition, and either:

Objective medical evidence that confirms the severity of the alleged pain arising from that condition; or

The objectively determined medical condition must be of such severity that it can reasonably be expected to give rise to the alleged pain.

Holt v. Sullivan, 921 F.2d 1221, 1223 (11th Cir. 1991).

A claimant’s subjective testimony supported by medical evidence that satisfies the pain standard is itself sufficient to support a finding of disability. Foote v. Chater, 67 F.3d 1553, 1561 (11th Cir. 1995). In certain situations, pain alone can be disabling, even when its existence is unsupported by objective evidence. Id. A claimant may establish that his pain is disabling through objective medical evidence that an underlying medical condition exists that could reasonably be expected to produce the pain. Id. If the ALJ rejects a claimant’s complaints of pain, “he must explicitly state as much and give reasons for that determination.” Id.,citingParker v. Bowen, 788 F.2d 1512, 1520 (11th Cir. 1986). “Failure to state a reasonable basis for rejection of such testimony mandates the testimony be accepted as true ‘as a matter of law.’” Id., citingHolt v. Sullivan, 921 F.2d 1221, 1223 (11th Cir. 1991).

D.C. Circuit

While it is true that 42 U.S.C. § 423(d)(5)(A) does not require medical evidence of pain itself, the statute does require “objective medical evidence of an underlying impairment which could cause such pain.” Smalls v. Shalala, 996 F.2d 413, 418 (D.C. Cir. 1993), citingBrown v. Bowen, 794 F.2d 703, 706 n. 4 (D.C. Cir. 1986) (emphasis in original). The Smalls court noted that “it is well within the ALJ’s province to consider whatever medical evidence of pain or other symptoms exists, as well as [the claimant’s] statements and those of her physicians.” Id.The mere fact that working may cause a claimant pain or discomfort does not mandate a finding of disability. Brown v. Bowen, 794 F.2d 703, 707 (D.C. Cir. 1986).

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